Developing Meaningful Metrics for Post-Acute Care Provider Networks

by Timothy Gieseke MD, CMD

Recently, I read with interest a report on the efforts of the Cleveland Clinic and Baystate Medical Center (Massachusetts) to develop a preferred Post-Acute Provider Network.

In my area, both of the referral hospitals have been meeting with community SNFs to better coordinate care transitions and reduce readmissions.  I have been invited to attend one of the hospitals monthly care coordination meetings where the focus has been on presenting readmission data and attempting to understand what could have gone better.  In addition, there have been brief discussions on improving palliative care, diabetes care, and other clinical topics. I’m not aware of either hospital narrowing their networks of providers as in the above article, but suspect the discharge planners do have their preferences based on similar metrics.

As a physician concerned about delivering high quality care in the Post-Acute setting, I believe that hospital SNF partnerships could consider more granular metrics for care that likely will impact readmission rate, length of stay, and patient satisfaction with care.  These metrics aren’t currently considered standard of care, but fall into the category of best practices that are likely adoptable, if incentivized by the partnership.

  1. Admitting Physicians should review the electronic medical records of the local referral hospital at the time they are admitting a patient and include that information in their H&P.

  2. The admitting H&P should be typed and should identify the patient’s PCP (or need to identify one) and pertinent specialists.  This document should comment on advance care planning conversations, decision making capacity, and pre-hospital functional status and living situation.

  3. The admitting physician should document an effort to reach the patient’s DPOA or designated contact person (or their inability to initiate contact due to patient declining permission).

  4. This H&P should be faxed to the identified PCP and pertinent specialists

  5. The attending physician or designated NP/PA should see the patient at least weekly while they are on Medicare Part A

  6. The patient should be seen by the attending physician or NP/PA prior to discharge. Medication reconciliation should be completed at that time and documented in a typed discharge summary.

  7. A copy of this discharge summary should be faxed to the patient’s PCP and pertinent specialists.

  8. An appointment should be made for follow up care with the patients PCP within once week of discharge from the SNF.  

  9. The facility should implement evidenced based tools to reduce readmissions like the INTERACT ( Stop and Watch Tool for CNAs, SBAR change of condition tool and Care Pathway tools for licensed nurses, and transfer checklist for when patients are transferred back to the acute setting.

  10. Acute hospitals should audit their transfer orders to insure that they have all the necessary order elements as well as set up a feedback loop so their SNF partners can give them feedback on incomplete or problem admission orders.

  11. Facilities should track and report the number of patients who after 1 week in their facility still have orders for sliding scale insulin w/o basal insulin.

  12. Medical conditions with high risk for relapse should be discussed at monthly meetings of the partnership and new knowledge disseminated.

  13. The partnership could develop a uniform patient satisfaction survey that the hospital sends out to their patients referred for post-acute care.  This could then be shared with facilities in a blinded fashion for their QI work.

I realize these aren’t CMS driven performance requirements, but believe experts in post-acute care would encourage the adoption of many of these elements as a way of optimizing care and patient outcomes at a lesser system cost.  I know that Kaiser Permanente in Northern California has implemented 1-8 for their continuity of care teams.